The Incidence of Surgical Cancellations: Lessons Learned from the Resumption of Elective Orthopaedic Operating after the First Wave of COVID-19

Category: Ankle;Other Introduction/Purpose: In the aftermath of the first wave of COVID-19, there was a significant backlog of elective orthopaedic cases. To address this problem, efficient running of theatres with optimal theatre utilisation was paramount. However, as new processes were introduced to reduce transmission risk, 'last-minute' cancellations of patients were inevitable. We report our experience of resuming elective work, with particular focus on surgical cancellations, and lessons learned. Methods: This was a retrospective, single centre audit at a specialist elective orthopaedic hospital. We identified and examined all cancellations in foot and ankle cases between June and October 2020. Data was analysed and cancellations were categorised into groups by reason of cancellation. Results: There were 36 cancellations out of 193 patients listed (19%). Twenty-one cancellations (57%) were directly related to COVID-19 and its processes. These comprised six patients (17%) with COVID-19 swab related issues including: booking errors, transport problems, non-attendance, and invalid swabs. Three patients (8%) contracted COVID-19 preoperatively. Nine patients (25%) cancelled their procedure at short notice amidst fears of contracting COVID-19 perioperatively. Three (8%) cancellations were due to the patient being unfit on the day of surgery - these issues were not routinely identified at pre-assessment appointments as face-to-face pre-assessment clinics had been suspended. A further 15 cancellations (42%) were due to non- COVID-19 reasons including lack of beds, unwell patients, and patients cancelling for other personal reasons. Conclusion: Mitigation of cancellations is a key factor in maintaining theatre utilisation. Based on our experience we recommend thorough counselling of patients regarding the importance of self-isolation prior to surgery and of the pre-operative swab. Having a designated team to manage COVID-19 swabs is also critical. Reinstatement of face-to-face pre-operative assessments may help identify evolving issues and prevent last-minute cancellations. These lessons are pertinent to trusts, particularly as we emerge from subsequent waves of COVID-19.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit.

OBJECTIVES: The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns. SETTING: This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020. PARTICIPANTS: All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection). RESULTS: 10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd's Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways. CONCLUSIONS: There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

The UK Foot and Ankle COVID-19 National (FAlCoN) audit.

AIMS: The primary objective was to determine the incidence of COVID-19 infection and 30-day mortality in patients undergoing foot and ankle surgery during the global pandemic. Secondary objectives were to determine if there was a change in infection and complication profile with changes introduced in practice. METHODS: This UK-based multicentre retrospective national audit studied foot and ankle patients who underwent surgery between 13 January and 31 July 2020, examining time periods pre-UK national lockdown, during lockdown (23 March to 11 May 2020), and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included. A total of 43 centres in England, Scotland, Wales, and Northern Ireland participated. Variables recorded included demographic data, surgical data, comorbidity data, COVID-19 and mortality rates, complications, and infection rates. RESULTS: A total of 6,644 patients were included. Of the operated patients, 0.52% (n = 35) contracted COVID-19. The overall all-cause 30-day mortality rate was 0.41%, however in patients who contracted COVID-19, the mortality rate was 25.71% (n = 9); this was significantly higher for patients undergoing diabetic foot surgery (75%, n = 3 deaths). Matching for age, American Society of Anesthesiologists (ASA) grade, and comorbidities, the odds ratio of mortality with COVID-19 infection was 11.71 (95% confidence interval 1.55 to 88.74; p = 0.017). There were no differences in surgical complications or infection rates prior to or after lockdown, and among patients with and without COVID-19 infection. After lockdown the COVID-19 infection rate was 0.15% and no patient died of COVID-19. CONCLUSION: COVID-19 infection was rare in foot and ankle patients even at the peak of lockdown. However, there was a significant mortality rate in those who contracted COVID-19. Overall surgical complications and postoperative infection rates remained unchanged during the period of this audit. Patients and treating medical personnel should be aware of the risks to enable informed decisions. Cite this article: Bone Joint Open 2021;2(4):216-226.

The UK foot and ankle COVID-19 national (FAlCoN) audit - Regional variations in COVID-19 infection and national foot and ankle surgical activity.

AIMS: This paper details the impact of COVID-19 on foot and ankle activity in the UK. It describes regional variations and COVID-19 infection rate in patients undergoing foot and ankle surgery before, during and after the first national lock-down. PATIENTS & METHODS: This was a multicentre, retrospective, UK-based, national audit on foot and ankle patients who underwent surgery between 13th January and 31st July 2020. Data was examined pre- UK national lockdown, during lockdown (23rd March to 11th May 2020) and post-lockdown. All adult patients undergoing foot and ankle surgery in an operating theatre during the study period included from 43 participating centres in England, Scotland, Wales and Northern Ireland. Regional, demographic and COVID-19 related data were captured. RESULTS: 6644 patients were included. In total 0.53% of operated patients contracted COVID-19 (n = 35). The rate of COVID-19 infection was highest during lockdown (2.11%, n = 16) and lowest after lockdown (0.16%, n = 3). Overall mean activity during lockdown was 24.44% of pre-lockdown activity with decreases in trauma, diabetic and elective foot and ankle surgery; the change in elective surgery was most marked with only 1.73% activity during lock down and 10.72% activity post lockdown as compared to pre-lockdown. There was marked regional variation in numbers of cases performed, but the proportion of decrease in cases during and after lockdown was comparable between all regions. There was also a significant difference between rates of COVID-19 and timing of peak, cumulative COVID-19 infections between regions with the highest rate noted in South East England (3.21%). The overall national peak infection rate was 1.37%, occurring during the final week of lockdown. General anaesthetic remained the most common method of anaesthesia for foot and ankle surgery, although a significant increase in regional anaesthesia was witnessed in the lock-down and post-lockdown periods. CONCLUSIONS: National surgical activity reduced significantly for all cases across the country during lockdown with only a slow subsequent increase in elective activity. The COVID-19 infection rate and peaks differed significantly across the country.